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Differentiation of self reflects the ability to define authentic life goals without needing the ap- proval of one’s family buy 40 mg zocor amex cholesterol levels change with age, while at the same time remaining in active emotional contact with them purchase 40mg zocor overnight delivery ldl cholesterol in shrimp. The goal for both men and women would be to define a self that expresses our need for individuality, while at the same time, ac- knowledging our continuing need for togetherness. Thus, the critique that Bowen theory idealizes emotional separateness and masculine gender role values is not accurate. Bowen’s origi- nal theory, in its acceptance of our culture’s binary definition of gender, failed to acknowledge the ways in which this binary system automatically encouraged men and women to give up self. Bowen theory does not acknowledge that husbands and wives have differing amounts of power and therefore differ in their flexibility, both to initiate change and to resist the system’s pressure not to change. It is these two aspects of Bowen theory—its failure to address both the ways in which gender roles encourage women and men to give up self and the inequalities between men and women within patriarchal culture—that limit its sensi- tivity to feminist goals. Traditional gender roles can be seen as examples of cultural prescriptions that are transmitted unconsciously through the multigenerational transmis- sion process. The traditional feminine gender role prescribes that women be- come facilitating environments for others, rather than defining and pursuing personal goals that are not related to family roles. A woman can now have per- sonal goals, primarily work-related goals, but if she is a wife and mother, she still must remain a facilitating environment for her husband and children. Masculine gender role prescriptions socialize men to focus on achieve- ment in the world of paid employment and to deny their need for intimacy and closeness. The more modern masculine role prescribes that men must be nurturing fathers, even while they remain the primary providers for their families. However, this continuing focus on economic provision keeps men away from their families and makes intimate relationships with their children exceedingly difficult. It is especially interesting that Bowen did not understand the function of gender roles in family systems, because he was extremely clear about the 106 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES function of sibling positions. Bowen integrated Walter Toman’s (1961) re- search on sibling position into family systems theory. Toman suggested that certain fixed personality characteristics were determined by an indi- vidual’s place in the sibling configuration of their family. For example, Toman found that oldest children tend to be overly responsible, naturally accepting responsibility for what needs to be done. A youngest child, in contrast, tends to assume that others will get things done and that he will be taken care of. The concept of functioning sibling position predicted that people from different classes, races, and cultures would have certain personality char- acteristics in common if they shared the same sibling position within their families of origin. Family systems theory assumes that as long as one indi- vidual performs certain functions, other individuals will not perform those functions. Similarly, feminist theory argues that gender socialization in childhood prepares men and women to assume the functional positions of wife/ mother or husband/father. Women overdevelop personality characteristics that are appropriate for functioning in the private world of the family (i. The family is the emotional milieu within which cultural expectations about gender roles are transmitted. In terms of the invisibility of power within Bowen theory, again its ab- sence is especially interesting, because the theory is clear about power dif- ferentials between parents and adolescents. From a Bowen family systems perspective, it is often advantageous to work with only one person in a fam- ily. Bowen theory assumes that change on the part of one person within the system automatically and in- evitably generates pressure within the system to encourage that person to change back into the old way of doing things. Because adolescents are not economically self-supporting, they are seen as not having enough power to withstand the family’s demand to change back. Although Bowen family systems therapy is often practiced with only one member of the family in the room, therapy with an adolescent alone is never recommended. Within this framework, power is acknowledged as being linked to generation, but not to gender. If we consider the economic context of full-time wives, however, they cer- tainly are not economically independent. Feminist family therapists (Bograd, 1986; Gold- ner, 1989; Lerner, 1988) have pointed out that these economic inequalities generate corresponding power inequalities between husbands and wives. Bowen Family Systems Theory as Feminist Therapy 107 In addition to the absence of gender in Bowen theory, there was also an absence of sensitivity to issues of race and class.

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Yang buy zocor 40 mg without prescription cholesterol test pin prick, the male princi- ple cheap 20mg zocor free shipping cholesterol definition for biology, represents the positive pole, heat, the sun, daytime, strength, en- ergy. All of creation is the result of a subtle equilibrium between the yin and the yang, whose union is expressed in every being and every object that populates the universe. Energy balance is the balance of the yin and the yang within the same body — although that does not mean that the two poles are equal. Disease was considered an expression of a disturbance in this in- ternal energy balance — too much (or not enough) yin, or too much (or not enough) yang. This notion of energy equilibrium goes hand in hand with a theory of the origins of the world that is based on five elements: wood, fire, earth, metal and water. Every expression of nature (including pathologies) is the complex result of the predominance of one or more of these ele- ments, together with the balance or the disturbance of the energy bal- ance. This gives you some idea of how complex the theoretical bases of Chinese medicine were; and the Chinese were familiar with traditional anatomy, as well, although they sometimes re-interpreted and cor- rected it to "adhere" to the requirements of the Taoist doctrines. For example, besides the "traditional" organs (liver, heart, spleen, pancreas, lungs, kidneys, stomach, bladder, small intestine, large intes- tine, gall bladder), man and woman were endowed with an additional 3 organ: the great heat source, which does not have any equivalent in 4 traditional W estern medicine. Each of these organs has a correspond- ing meridian line that goes from the surface of the skin to the organ in question, and to the end of the limbs. These are the "subtle channels" that enable the yin/yang energy to circulate and to manage the organ- 54 Needles and Pains ism’s equilibrium. The technique of acupuncture would be developed to bring en- ergy (toning up) or remove energy (dispersion) at the level of one acu- punctural point. The acupuncturist acts not only in the physiological plane; he works to restore the human being to the "sacred" balance of the Tao. The needle as an antenna: In a way, the needle can be compared to an antenna that connects the internal world to its environment. This interpretation goes with the concept that the needle is regarded as a link between man and "heaven" (the environment). This aspect of acupuncture seems to have taken root as soon as the tool was in- vented: it dates back to the bronze age in China, that is to say around the 17th century before Jesus Christ. And even if, since then, the forms and dimensions have been diversified to correspond with various therapeutic needs, the same inspiration continues to dominate the symbolism. As proof, the traditional range of acupuncture tools com- prises nine needles; in Chinese numerologic tradition, the number nine corresponds to "heaven". Thus, the needle remains an intermedi- ary between "heaven" and man, that is, between man and his sur- 5 roundings. The points are indexed in various treatises, the principal one be- ing the Yellow Emperor’s Book of Internal Medicine, but practitioners do not entirely agree on how many points there are: from 160 to as many as 650. It should be noted that the "great Chinese medical tradition" needed a decree from the W orld Health Organization to set the final number of points at 361. W HO, to our knowledge, has not yet weighed in with any legisla- tion to standardize the various pulses by which a Chinese doctor can make his energy diagnosis. The Book of the Yellow Emperor describes twelve anatomical locations where the pulse can be felt, but there are fifteen types of pulses (described in the Book of the Pulse, written in 55 Healing or Stealing? Each radial pulse is divided into twelve parts, corresponding to each meridian line — for which the fifteen types of pulse can be de- tected. Apparently, Chinese civilization has not been without its own share of quacks and charlatans. If we take the base of twelve pulses, with the twelve meridian lines and the fifteen types of pulse, there are several million possible combinations; and in theory, a different diagno- sis should be made for each one! The practice has had to be simplified as it evolved, and various artifices have been devised to help. Today there are practically diagnos- tic abacuses which, while they may not work, are nonetheless beautiful works of art. The W est, which has always been a sucker for easy solu- tions, uses acupuncture point detectors based on the principle of the ohmmeter.

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The questions which best lend them selves to the RCT design are all about interventions cheap 10mg zocor with amex cholesterol levels in cheese, and are m ainly concerned with therapy or prevention order zocor 40mg amex cholesterol rich foods. It should be rem em bered, however, that even when we are looking at therapeutic interventions, and especially when we are 47 H OW TO READ A PAPER not, there are a num ber of im portant disadvantages associated with random ised trials (see Box 3. There are, in addition, m any situations in which RCTs are either unnecessary, im practical or inappropriate. Som e people would argue that it is actually unethical to ask patients to be random ised to a clinical trial without first conducting a system atic literature review to see whether the trial needs to be done at all. RCTs are inappropriate • W here the study is looking at the prognosis of a disease. For this analysis, the appropriate route to best evidence is a longitudinal survey of a properly assem bled inception cohort (see section 3. For this analysis, the appropriate route to best evidence is a cross-sectional survey of patients clinically suspected of harbouring the relevant disorder (see section 3. For exam ple, an RCT com paring m edical versus surgical m ethods of abortion m ight assess "success" in term s of num ber of patients achieving com plete evacuation, am ount of bleeding, and pain level. The patients, however, m ight decide that other aspects of the procedure are im portant, such as knowing in advance how long the procedure will take, not seeing or feeling the abortus com e out, and so on. For this analysis, the appropriate route to best evidence is a qualitative research method47 (see Chapter 11). All these issues have been discussed in great depth by the clinical epidem iologists,3, 6 who rem ind us that to turn our noses up at the 49 H OW TO READ A PAPER non-random ised trial m ay indicate scientific naïveté and not, as m any people routinely assum e, intellectual rigour. N ote also that there is now a recom m ended form at for reporting RCTs in m edical journals, which you should try to follow if you are writing one up yourself. The follow up period in cohort studies is generally m easured in years (and som etim es in decades), since that is how long m any diseases, especially cancer, take to develop. N ote that RCTs are usually begun on patients (people who already have a disease), whereas m ost cohort studies are begun on subjects who m ay or m ay not develop disease. A group of patients who have all been diagnosed as having an early stage of the disease or a positive screening test (see Chapter 7) is assem bled (the inception cohort) and followed up on repeated occasions to see the incidence (new cases per year) and tim e course of different outcom es. They followed up 40 000 British doctors divided into four cohorts (non- sm okers, light, m oderate and heavy sm okers) using both all cause (any death) and cause specific (death from a particular disease) m ortality as outcom e m easures. Publication of their 10 year interim results in 1964,51 which showed a substantial excess in both lung cancer m ortality and all cause m ortality in sm okers, with a 50 G ETTIN G YOU R BEARIN G S "dose–response" relationship (i. The 20 year52 and 40 year53 results of this m om entous study (which achieved an im pressive 94% follow up of those recruited in 1951 and not known to have died) illustrate both the perils of sm oking and the strength of evidence that can be obtained from a properly conducted cohort study. Clinical questions which should be addressed by a cohort study include the following. As John Guillebaud has argued in his excellent book the Pill,54 if 1000 wom en went on the pill tom orrow, som e of them would get breast cancer. The question which epidem iologists try to answer through cohort studies is "W hat is the additional risk of developing breast cancer which this wom an would run by taking the pill, over and above her "baseline" risk attributable to her own horm onal balance, fam ily history, diet, alcohol intake, and so on? D ata are then collected (for exam ple, by searching back through these people’s m edical records or by asking them to recall their own history) on past exposure to a possible causal agent for the disease. Like cohort studies, case-control studies are generally concerned with the aetiology of a disease (i. An im portant source of difficulty (and potential bias) in a case-control study is the precise definition of who counts as a "case", since one m isallocated subject m ay substantially influence the results (see section 4. In addition, such a design cannot dem onstrate causality; in other words, the association of A with B in a case-control study does not prove that A has caused B. Clinical questions which should be addressed by a case-control study include the following. Surveys conducted by epidem iologists are run along essentially the sam e lines: a representative sam ple of subjects (or patients) is interviewed, exam ined or otherwise studied to gain answers to a specific clinical question. In cross- sectional surveys, data are collected at a single tim epoint but m ay refer retrospectively to health experiences in the past, such as, for exam ple, the study of patients’ casenotes to see how often their blood pressure has been recorded in the past five years. Clinical questions which should be addressed by a cross- sectional survey include the following. But such an exercise does not answer the related clinical question "W hen should an unusually short child be investigated for disease? Case reports are often run together to form a case series, in which the m edical histories of m ore than one patient with a particular condition are described to illustrate an aspect of the condition, the treatm ent or, m ost com m only these days, adverse reaction to treatm ent.

Lichtenstein and Slovic showed in 1971 that both experimental subjects and real gamblers in a Las Vegas casino frequently and characteristically reversed preferences when their choices between alternative bets were compared with prices they would pay for the same alternative bets order 40 mg zocor fast delivery cholesterol ratio ideal. PREFERENCE buy 40 mg zocor mastercard cholesterol score of 182, UTILITY AND VALUE IN MEANS AND ENDS 127 First, the subjects were asked which of the bets they would choose. Although an approximately equal number of subjects chose each alternative bet, the $ bet was assigned a higher selling price about 88% of the time. Slavic notes "of participants who chose the P bet, 87% gave a higher selling price to the $ bet. In the example above, from Slovic’s early work, different procedures for determining the worth of a bet, i. Tversky and Kahneman found that preference reversals could be induced by alterations in the framing of situations. It appears that people avoid losses more fiercely than they seek gains in many settings. If Program C is chosen, 400 people will die, and if Program D is chosen, there is a 1/3 chance that no one will die and a 2/3 chance that 600 people will die. In problem one the reference state is 600 deaths and events are described as "lives saved. When our attention is focused on deaths, we seem unable to give lives saved the same value as when our attention is focused on lives saved. It appears that it is difficult to hold two different considerations before the mind in an equally vivid and efficacious fashion, even when the two considerations are so closely related as life and death. The difficulty has been shown to exist when patients are presented with information relating to possible outcomes of treatment such as the risk of immediate death, average length of survival, monetary costs, probability of disability, likelihood, type and intensity of pain, etc. One studied example showed preference reversals in choices between hypothetical radiation and surgical treatments for lung cancer depending on how the alternative outcomes were framed. We should expect 128 CHAPTER 5 people to come up with a variety of strategies for choosing among incomparables, and to find that not all of these are consistent or even stable. Amos Tversky, Paul Slovic and Shmuel Sattah studied differences between "choice" and "matching" procedures for making decisions about alternatives which vary on two or more dimensions. Salary: $20,000 Location: San Francisco Prestige of program: Medium Collegiality in program: High Option B. Salary: $25,000 Location: Detroit Prestige of program: High Collegiality in program: Medium A graduating medical student could choose between these options by picking on the basis of her most important concern, say prestige or location, or by deciding to take the option which is superior on more of the three most important aspects, or by eliminating an option which fell below a certain standard on any one aspect, to name three of many possible choice procedures. Alternatively, the student could try to match the options by weighting individual aspects more quantitatively in terms of their importance, then sizing the discrep- ancies among the choices on each aspect, and comparing the totals. This procedure, matching, involves trying to imagine what each value is worth in terms of another, for example, what salary sacrifice it is worth making to live in San Francisco instead of Detroit. Obviously, it is harder to estimate how "much" collegiality one would "pay" to get a higher salary or for a more prestigious program, but people do attempt these things, especially when experimenters tell them they have to. Different choice procedures could result not only in different evaluations, but in opposite judgments and decisions, depending on the task. The authors propose a formal theory of "contingent weighting" to account for how procedural variance elicits different valuations. I will not attempt an exposition of their theory here, but refer the reader to the original article. The relevant point here is that marked lability PREFERENCE, UTILITY AND VALUE IN MEANS AND ENDS 129 of preference was exhibited in these experimental settings. The authors comment that this lability " raises difficult questions concerning the assessment of preferences and values. In the classical analysis, the relation of preference is inferred from observed responses (e. But if different elicitation procedures produce different orderings of options, how can preferences and values be defined? To be sure, people make choices, set prices, rate options and even explain their decisions to others. However, if these data do not satisfy the elementary requirements of [procedure] invariance, it is unclear how to define a relation of preference that can serve as a basis for the measurement of value.

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